Morpot Tgl 19 November

Mr A ( 34 YO)Mekanisme of the trauma :motorcycle crash Injury of target organ : regio labialis posteriorSymptoms and signs : pain on the bruiseTransport : by car

PRIMARY SURVEYAirway : clear ( no snoring, no gargling, no stridor) conclusion : clear.

Breathing :Inspeksi : bruise -, chest wall movement symmetrical, RR 20x/min, hematom –Palpasi : crepitation – pain (-)Perkusi : sonor right = leftAuskultasi : basic breath sound vesikuler

HISTORY OF ILNESS±30 minute before enter to hospital patient have an motorcycle accident. when patients are riding motorcycles fast and heavy rain, and the patient's motor slip hit car in front. patient could not avoid the sudden stop. patients eventually fell and bloody lip patients because a tear. no head injury, no collision chest, no fainting, no amnesia, no vomiting, no nausea.

PRIMARY SURVEYC : warm extremities, Pulse = 82 x/mnt , BP: 120/80mmHg, Temp= 360C, capillary refill <2”

Conclusion : no sign of shock

PRIMARY SURVEYDisability

GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex/indirect light reflex +/+

Exposure no life-threatening injury

Secondary Survey Chief complaint : pain on the bruise Additional complaint : weakness

SECONDARY SURVEY

HEAD TO TOE

regio frontalis dextraLook : vulnus eksoriasi(+), jejas (+), edema (-)Feel : pain (+) , crepitation (-)Move : dorso flexi +, anteflexi +, abduksi +,

adduksi +

SECONDARY SURVEYEyes : Pupil circular, isochoric

3mm/3mm, conjuntiva anemis -/-, sclera icteric -/-

Ear : secret -/-, blood -Nose : secret -/-, blood -Neck : bruise - , hematom -

Thorax :Insp : movement of chest wall

symmetrical Pal : vocal fremitus right = left Per : sonor right = left Aus : vesiculer, rhonki -/-, wheezing

-/-

Abdomen :Ins : flat, bruise (-), mass (-)Aus : bowel sound (+) 4times/minutePal : tenderness (-)Per : tympani, percussion pain (-) Ekstremitas : warm extremities, cap. refill < 2”, edema (-)

DIAGNOSIS

CKR + Vulnus laceratum

TREATMENT

Patient not hospitalized Wound toilet Hecting Observasi

Medication Analgetic Antibiotic

3. Mr H ( 21 YO)Mekanisme of the trauma : accident a suicide

attempt Injury of target organ : Regio antebrachii

sinistraSymptoms and signs : pain on the bruiseTransport : by motorcycle

HISTORY1 hour before to hospital, the

patient had an accident a suicide attempt for arguing with his girlfriend, patients slashing his left hand with a razor blade to cause open sores and bleeding. before the patient was taken to the clinic, but only wound bandaged it. eventually the patient to the hospital uki.

PRIMARY SURVEY Airway : clear ( no snoring, no gargling, no stridor) conclusion : clear.Breathing : Inspeksi : bruise -, chest wall movement

symmetrical, RR 24x/min, hematom – Palpasi : crepitation – Perkusi : sonor right = left Auskultasi : basic breath sound vesikuler

PRIMARY SURVEYCirculation : warm extremities, Pulse = 82 x/mnt , BP: 140/100mmHg, Temp= 360C, Respiration Rate : 24x/menit, capillary refill <2”

Conclusion : no sign of shock

PRIMARY SURVEY Disability

GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex/indirect light reflex +/+

Exposure

no life-threatening injury

Secondary Survey Chief complaint : pain and bleeding

on the bruise Additional complaint : weakness

Status localis 1. Regio antebrachiiLook : jejas (+), bruise (+), bleeding (+), edema (-)Feel : pain in woundMove : flexi +, anteflexi +, abduksi +, adduksi +

Eyes : Papil circular, isochoric 3mm/3mm,conjuntiva anemis -/-, sclera icteric -/-

Ear : secret -/-, blood -Nose : secret -/-, blood -Neck : bruise - , hematom

-

Thorax :Insp : movement of chest wall

symmetrical Pal : vocal fremitus right = left Per : sonor right = left Aus : vesiculer, rhonki -/-, wheezing

-/-

Abdomen :Ins : flat, bruise (-), mass (-)Aus : bowel sound (+) 4 times/minutePal : tenderness (-)Per : tympani, percussion pain (-) Ekstremitas : warm extremities, cap. refill < 2”, edema (-)

DIAGNOSIS

Vulnus Lacseratum e.c sharps

TREATMENT

Patient pro hospitalized Wound toilet Hecting

Medicamentosa- Analgetic- Antibiotic